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RHIA Practice Exam 1 Questions and Answers (100% Pass)
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RHIA Practice Exam 1 Questions and Answers (100% Pass)
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©PREP4EXAMS@2024 [REAL EXAM DUMPS] Tuesday, July 23, 2024 10:52 AMRHIA Practice Exam 1 Questions and
Answers (100% Pass)
Smith was admitted to a nursing facility with the following information: "patient is being
admitted for Organic brain syndrome." Underneath the diagnosis her medical information was
listed along with a summary of the care already provided. This information is documented on
the: - ✔️✔️Transfer recrod
A 65-year-old white male was admitted to the hospital 1/15 complaining of abdominal pain. The
attending physician requested an upper GI series and laboratory eval of CBC and UA. The x-ray
revealed possible problems and the UA showed an increased white blood cell count. The patient
was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered.
The chief complaint was: - ✔️✔️Abdominal pain
Smith's admitting data indicates that her birthdayis 5/21/14. On the discharge summary, Smith's
birth date is recorded as July 21. What quality element is missing from Mrs. Smith's health
record? - ✔️✔️Data consistency
When defining the legal health record in a healthcare entity, it is best practice to establish a
policy statement of the legal health record as well as a: - ✔️✔️Health record matrix
Erin is the HIM director at anywhere hospital. She is teaching a class to clinicians about proper
documentation in the health record. what should she instruct them to do: - ✔️✔️Leave existing
entries intact. Label late entries as being late. Ensure the legal signature of an individual making
a correction accompanies the correction.
All documentation entered in the medical record relating to the patient's diagnosis and treatment
are considered this type of data: - ✔️✔️Clinical
Data that have been grouped into meaningful categories according to a classification system are
referred to as ________ data. - ✔️✔️Coded
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,©PREP4EXAMS@2024 [REAL EXAM DUMPS] Tuesday, July 23, 2024 10:52 AM
Conducting an inventory of the facility's records, determining the format and location of record
storage, assigning each record a time period for preservation and destroying records that are no
longer needed are all elements of a: - ✔️✔️retention program
What is the principal function of health records? - ✔️✔️Serve as the repository of clinical
documentation relevant to the care of individual patients
The insured party's member identification number is an example of what type of data: -
✔️✔️financial data
What part of the problem-oriented medical record is used by many facilities that have adopted
the whole problem-oriented format? - ✔️✔️The SOAP progress notes
What materials are required element in an emergency care record? - ✔️✔️Time and means of the
patient's arrival, treatment rendered, and instructions at discharge
What type of information makes it easy for hospitals to compare and combine the contents of
multiple patient health record - ✔️✔️uniform data set
What is a unique identifier in the relational database patient table - ✔️✔️Patient number
What is used by a long-term facility to gather information about specific health status factors and
includes information about specific risk factors in the resident's care? - ✔️✔️minimum data set
In a long-term care setting, these are problem-oriented frameworks for additional patient
assessment based on problem identification items: - ✔️✔️Utilization guidelines
Documenting the full depth and breadth of data use in a healthcare entitiy requires: -
✔️✔️Identifying the needs of data consumers
What is an example of a M-M relationship? - ✔️✔️Patients to consulting physicians
What is a M-M relationship? - ✔️✔️Many to many
Mrs. Smith was admitted to a hospital by Dr. Collins. Mrs. Smith's hospital bill was paid by Blue
Cross insurance. Upon discharge from the hospital, who owns the health record of Mrs. Smith? -
✔️✔️University Hospital
Decision making and authority over data-related matters is known as: - ✔️✔️data governance
Abbreviations can be a source of patient safety issues due to misinterpretation and
miscommunication. Abbreviations in the health record: - ✔️✔️Should only have one meaning
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, ©PREP4EXAMS@2024 [REAL EXAM DUMPS] Tuesday, July 23, 2024 10:52 AM
In ICD-10-PCS what value is used if there is a character that does not apply to a given code? -
✔️✔️Z
The primary responsibility of a coder is to: - ✔️✔️ensure quality of coded data
Documentation including the the date of action, method of action, description of the disposed
record series of numbers or items, services dates, a statement that the records were eliminated in
the normal course of business, and the signatures of the individuals supervising and witnessing
the process must be included in this: - ✔️✔️certificate of destruction
What is the data model that is most widely used to illustrate a relational database structure? -
✔️✔️Entity-relationship diagram (ERD)
Anywhere hospital has mandated that the social security number will be displayed in the XXX-
XX-XXXX format for their patients. This is an example of the use of a: - ✔️✔️Mask
What is a system in which the patient health record is kept in the same order on the nursing
station and in the complete record? - ✔️✔️Universal
Data that are collected on large populations of individuals and stored in databases are referred to
as: - ✔️✔️aggregate data
The data elements in a patient's automated laboratory result are examples of: - ✔️✔️structured data
According to JC accreditation standards, what document must be placed in the patient's record
before a surgical procedure may be performed? - ✔️✔️Report of history and physical examination
Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health
record together for an authorized request for information? - ✔️✔️It can exist in separate and
multiple paper-based or electronic systems
Data mapping is used to harmonize data sets or code sets. The code or data set from which the
map originates is the: - ✔️✔️source
The process by which a person or entity who authored an EHR entry or document seeks to
validate that they are responsible for the data contained within it is called: - ✔️✔️authentication
Notes written by physicians and other practitioners as well as dictated and transcribed reports are
examples of: - ✔️✔️unstructured clinical information
A significant challenge when handling hybrid records is complicated by the fact that: - ✔️✔️The
requirements, regulations, and constraints of EHRs and paper records must be met
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